The contagiousness of puerperal fever

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THE

CONTAGIOUSNESS OF PUERPERAL FEVER.

READ BEFORE THE BOSTON SOCIETY FOR MEDICAL IMPROVEMENT, AND
PUBLISHED AT THE REQUEST OF THE SOCIETY.*

BY OLIVER W. HOLMES, M.D.

In collecting; enforcing and adding to the evidence accumulated
upon this most serious subject, I would not be understood to imply
that there exists a doubt in the mind of any well-informed member
of the medical profession as to the fact that puerperal fever is some-
times communicated from one person to another, both directly and
indirectly. In the present state of our knowledge upon this point
I should consider such doubts merely as a proof that the sceptic had
either not examined the evidence, or, having examined it, refused to
accept its plain and unavoidable consequences. I should be sorry to
think with Dr. Rigby, that it was a case of " oblique vision ; " I
should be unwilling to force home the argumentum ad hominem of#
Dr. Blundell, but I would not consent to make a question of a mo-
mentous fact, which is no longer to be considered as a subject for
trivial discussions, but to be acted upon with silent promptitude.
It signifies nothing that wise and experienced practitioners have
sometimes doubted the reality of the danger in question ; no man has
the right to doubt it any longer. No negative facts, no opposing

* From the New England Quarterly Journal of Medicine and Surgery. / 0 ^ti

2 Contagiousness of Puerperal Fever.

opinions, be they what they may or whose they may, can form any
answer to the series of cases now within the reach of all who choose
to explore the records of medical science.

If there are some who conceive that any important end would be an-
swered by recording such opinions, or by collecting the history of all
the cases they could find in which no evidence of the influence of
contagion existed, I believe they are in error. Suppose a few writers
of authority can be found to profess a disbelief in contagion — and
they are very few compared with those who think differently — is it
quite clear that they formed their opinions on a view of all the facts,
or is it not apparent that they relied mostly on their own solitary ex-
perience ? Still further, of those whose names are quoted, is it not
true that scarcely a single one could by any possibility have known
the half or the tenth of the facts bearing on the subject which have
reached such a frightful amount within the last few years ? Again,
as to the utility of negative facts, as we may briefly call them, — in-
stances, namely, in which exposure has not been followed by disease,
— although, like other truths, they may be worth knowing, I do not
see that they are like to shed any important light upon the subject
before us. Every such instance requires a good deal of circumstan-
tial explanation before it can be accepted. It is not enough that a
practitioner should have had a single case of puerperal fever not fol-
lowed by others. It must be known whether he attended others
while this case was in progress, whether he went directly from one
chamber to others, whether he took any, and what precautions. It
is important to know that several women were exposed to infection
derived from the patient, so that allowance may be made for want of
predisposition. Now if of negative facts so sifted there could be ac-
cumulated a hundred for every one plain instance of communication
here recorded, I trust it need not be said that we are bound to guard
and watch over the hundredth tenant of our fold, though the ninety
and nine may be sure of escaping the wolf at its entrance. If any
one is disposed, then, to take a hundred instances of lives endanger-
ed or sacrificed out of those I have mentioned, and make it reasona-
bly clear that within a similar time and compass ten thousand escap-
ed the same exposure, 1 shall thank him for his industry, but I must
be permitted to hold to my own practical conclusions, and beg him
to adopt or at least to examine them also. Children that walk in
calico before open fires are not always burned to death ; the instances
to the contrary may be worth recording ; but by no means if they are
to be used as arguments against woollen frocks and high fenders.

Contagiousness of Puerperal Fever. 3

I am not sure that this paper will escape another remark which it
might be wished were founded in justice. It may be said that the
facts are too generally known and acknowledged to require any for-
mal argument or exposition, that there is nothing new in the posi-
tions advanced, and no need of laying additional statements before
the profession. But on turning to two works, one almost universal-
ly, and the other extensively appealed to as authority in this country,
I see ample reason to overlook this objection. In the last edition of
Dewees's Treatise on the Diseases of Females, it is expressly said,
" In this country, under no circumstance that puerperal fever has
appeared hitherto, does it afford the slightest ground for the belief
that it is contagious." In the " Philadelphia Practice of Midwifery "
not one word can be found in the chapter devoted to this disease,
which would lead the reader to suspect that the idea of contagion
had ever been entertained. It seems proper, therefore, to remind
those who are in the habit of referring to these works for guidance,
that there may possibly be some sources of danger they have slight-
ed or omitted, quite as important as a trifling irregularity of diet, or
a confined state of the bowels, and that whatever confidence a phy-
sician may have in his own mode of treatment, his services are of
questionable value whenever he carries the bane as well as the anti-
dote about his person.

The practical point to be illustrated is the following : The disease
known as Puerperal Fever is so far contagious as to be frequently
carried from patient to patient by physicians and nurses.

Let me begin by throwing out certain incidental questions, which
without being absolutely essential, would render the subject more
complicated, and by making such concessions and assumptions as
may be fairly supposed to be without the pale of discussion.

1. It is granted that all the forms of what is called puerperal fever
may not be, and probably are not, equally contagious or infectious.
I do not enter into the distinctions that have been drawn by authors,
because the facts do not appear to me sufficient to establish any ab-
solute line of demarcation between such forms as may be propagated
by contagion, and those which are never so propagated. This gene-
ral result I shall only support by the authority of Dr. Ramsbotham,
who gives as the result of his experience, that the same symptoms
belong to what he calls the infectious and the sporadic forms of the
disease, and the opinion of Armstrong in his original essay. If others

4 Contagiousness of Puerperal Fever.

can show any such distinction, 1 leave it to them to do it. But there
are cases enough that show the prevalence of the disease among the
patients of a single practitioner when the disease was in no degree
epidemic, in the proper sense of the term. I may refer to those of
Mr.ploberton and of Dr. Peirson, hereafter to be cited, as examples.

2. I shalPnot enter "into any dispute about the particular mode of
infection, whether it be by the atmosphere the physician carries
about him into the sick chamber, or by the direct application of the
virus to the absorbing surfaces with which his hand comes in contact.
Many facts and opinions are in favor of each of these modes of trans-
mission. But it is obvious that in the majority of cases it must be
impossible to decide by which of these channels the disease is con-
veyed, from the nature of the intercourse between the physician and
the patient.

3. It is not pretended that the contagion of puerperal fever must
always be followed by the disease. It is true of all contagious dis-
eases that they frequently spare those who appear to be fully sub-
mitted to their influence. Even the vaccine virus, fresh from the
subject, fails every day to produce its legitimate effect, though every
precaution is taken to ensure its action. This is still more remarka-
bly the case with scarlet fever and some other diseases.

4. It is granted that the disease may be produced and variously
modified by many causes besides contagion, and more especially by
epidemic and endemic influences. But this is not peculiar to the
disease in question. There is no doubt that smallpox is propagated
to a great extent by contagion, yet it goes through the same periods
of periodical increase and diminution which have been remarked in
puerperal fever. If the question is asked how we are to reconcile
the great variations in the mortality of puerperal fever in different
seasons and places with the supposition of contagion, I will answer
it by another question from Mr. Farr's letter to the Registrar-Gene-
ral. He makes the statement that "Jive die weekly of smallpox in
the metropolis when the disease is not epidemic " — and adds, " The
problem for solution is, — Why do the 5 deaths become 10, 15, 20,
31, 58, 88 weekly, and then progressively fall through the same mea-
sured steps? "

5. I take it for granted that if it can be shown that great numbers of
lives have been and are sacrificed to ignorance or blindness on this
point, no other error of which physicians or nurses may be occasion-
ally suspected will be alleged in palliation of this ; but that whenever

Contagiousness of Puerperal Fever. 5

and wherever they can be shown to carry disease and death instead
of health and safety, the common instincts of humanity will silence
every attempt to explain away their responsibility.

The treatise of Dr. Gordon, of Aberdeen, was published in the
year J 795, being among the earlier special works upon the disease.
A part of his testimony has been occasionally copied into other
works, but his expressions are so clear, his experience is given with
such manly distinctness and disinterested honesty, that it may be
quoted as a model which might have been often followed with ad-
vantage.

" This disease seized such women only as were visited, or deli-
vered, by a practitioner, or taken care of by a nurse, who had pre-
viously attended patients affected with the disease."

" I had evident proofs of its infectious nature, and that the infec-
tion was as readily communicated as that of the small-pox or measles,'
and operated more speedily than any other infection with which I
am acquainted."

" I had evident proofs that every person who had been with a pa-
tient in the puerperal fever became charged with an atmosphere of
infection, which was communicated to every pregnant woman who
happened to come within its sphere. This is not an assertion, but
a fact, admitting of demonstration, as may be seen by a perusal of
the foregoing table," — referring to a table of seventy-seven cases, in
many of which the channel of propagation was evident.

He adds, "It is a disagreeable declaration for me to mention, that
I myself was the means of carrying the infection to a great number
of women." He then enumerates a number of instances in which
the disease was conveyed by midwives and others to the neighboring
villages, and declares that "These facts fully prove, that the cause
of the puerperal fever, of which I treat, was a specific contagion, or
infection, altogether unconnected with a noxious constitution of the
atmosphere."

But his most terrible evidence is given in these words, " I arrived

AT THAT CERTAINTY IN THE MATTER, THAT I COULD VENTURE TO FORE-
TELL AVHAT WOMAN WOULD BE AFFECTED WITH THE DISEASE, UPON
HEARING BY WHAT MIDWIFE THEY WERE TO BE DELIVERED, OR BY
WHAT NURSE THEY WERE TO BE ATTENDED, DURING THEIR LYING IN .'■
AND, ALMOST IN EVERY INSTANCE, MY PREDICTION WAS VERIFIED."

Even previously to Gordon, Mr. White of Manchester had said, "I

6 Contagiousness of Puerperal Fever.

am acquainted with two gentlemen in another town, where the
whole business of midwifery is divided betwixt them, and it is very
remarkable that one of them loses several patients every year of the
puerperal fever, and the other never so much as meets with the dis-
order"— a difference which he seems to attribute to their various
modes of treatment.*

Dr. Armstrong has given a number of instances in his Essay on
Puerperal Fever, of the prevalence of the disease among the patients
of a single practitioner. At Sunderland, " in all, forty-three cases
occurred from the first of January to the first of October, when the
disease ceased ; and of this number forty were witnessed by Mr.
Gregson and his assistant Mr. Gregory, the remainder having been
separately seen by three accoucheurs." There is appended to the
London edition of this essay, a letter from Mr. Gregson, in which
that gentleman says, in reference to the great number of cases oc-
curring in his practice, " The cause of this I cannot pretend fully to
explain, but 1 should be wanting in common liberality if I were to
make any hesitation in asserting, that the disease which appeared in
my practice was highly contagious, and communicable from one pu-
erperal woman to another." " It is customary among the lower and
middle ranks of people to make frequent personal visits to puerperal
women resident in the same neighborhood, and I have ample evi-
dence for affirming that the infection of the disease was often carried
about in that manner ; and, however painful to my feelings, I must
in candor declare, that it is very probable the contagion was con-
veyed, in some instances, by myself, though I took every possible
care to prevent such a thing from happening, the moment that I as-
certained that the distemper was infectious." Dr. Armstrong goes
on to mention six other instances within his knowledge, in which the
disease had at different times and places been limited, in the same
singular manner, to the practice of individuals, while it existed
scarcely if at all among the patients of others around them. Two of
the gentlemen became so convinced of their conveying the contagion
that they withdrew for a time from practice.

I find a brief notice, in an American Journal, of another series of
cases, first mentioned by Mr. Davies, in the Medical Repository.
This gentleman stated his conviction that the disease is contagious.

" In the autumn of 1822, he met with twelve cases, while his med-

* On the Management of Lying-in Women, p. 120.

Contagiousness of Puerperal Fever. 7

ical friends in the neighborhood did not meet with any, 'or at least
very few.' He could attribute this circumstance to no other cause
than his having been present at the examination, after death, of two
cases, sometime previous, and of his having imparted the disease to
his patients, notwithstanding every precaution." *

Dr. Gooch says, " It is not uncommon for the greater number of
cases to occur in the practice of one man, whilst the other practi-
tioners of the neighborhood, who are not more skilful or more busy,
meet with few or none. A practitioner opened the body of a woman
who had died of puerperal fever, and continued to wear the same
clothes. A lady whom he delivered a few days afterwards was at-
tacked with and died of a similar disease ; two more of his lying-in
patients, in rapid succession, met with the same fate ; struck by the
thought, that he might have carried contagion in his clothes, he in-
stantly changed them, and met with no more cases of the kind.f A
woman in the country, who was employed as washerwoman and
nurse, washed the linen of one who had died of puerperal fever; the
next lying-in patient she nursed, died of the same disease ; a third
nursed by her met with the same fate, till the neighborhood getting
afraid of her, ceased to employ her."|

In the winter of the year 1824 " Several instances occurred of its
prevalence among the patients of particular practitioners, whilst
others who were equally busy met with few or none. One instance
of this kind was very remarkable. A general practitioner, in large
midwifery practice, lost so many patients from puerperal fever, that
he determined to deliver no more for some time, but that his partner
should attend in his place. This plan was pursued for one month,
during which not a case of the disease occurred in their practice.
The elder practitioner being then sufficiently recovered, returned to
his practice, but the first patient he attended was attacked by the
disease and died. A physician, who met him in consultation soon
afterwards, about a case of a different kind, and who knew nothing
of his misfortune, asked him whether puerperal fever was at all pre-
valent in his neighborhood, on which he burst into tears, and related
the above circumstances.

" Among the cases which I saw this season in consultation, four oc-

* Philad. Med. Journal for 1825, p. 408.

t A similar anecdote is related by Sir Benjamin Brodie, of the late Dr. John Clarke. Lan-
cet, May 2, 1840.
t An Account of some of the most important Diseases peculiar to Women, p. 4.

8 Contagiousness of Puerperal Fever.

curred in one month in the practice of one medical man, and all of
them terminated fatally." *

Dr. Ramsbotham asserted, in a lecture at the London Hospital,
that he had known the disease spread through a particular district,
or be confined to the practice of a particular person, almost every pa-
tient being attacked with it, while others had not a single case. It
seemed capable, he thought, of conveyance, not only by common
modes, but through the dress of the attendants upon the patient. f

In a letter to be found in the London Medical Gazette for Jan.,
1840, Mr. Roberton, of Manchester, makes the statement which I
here give in a somewhat condensed form.

A midwife delivered a woman on the 4th of December, 1830, who
died soon after with the symptoms of puerperal fever. In one month
from this date the same midwife delivered thirty women, residing in
different parts of an extensive suburb, of which number sixteen
caught the disease and all died. These were the only cases which
had occurred for a considerable time in Manchester. The other
midvvives connected with the same charitable institution as the
woman already mentioned, are twenty-five in number, and deliver,
on an average, ninety women a week, or about three hundred and
eighty a month. None of these women had a case of puerperal fe-
ver. " Yet all this time this woman was crossing the other midwives
in every direction, scores of the patients of the charity being deli-
vered by them in the very same quarters where her cases of fever
were happening."

Mr. Roberton remarks, that little more than half the women she
delivered during this month took the fever ; that on some days all
escaped, on others only one or more out of three or four ; a circum-
stance similar to what is seen in other infectious maladies.

Dr. Blundell says, " Those who have never made the experiment,
can have but a faint conception how difficult it is to obtain the exact
truth respecting any occurrence in which feelings and interests are
concerned. Omitting particulars, then, I content myself with re-
marking, generally, that from more than one district I have received
accounts of the prevalence of puerperal fever in the practice of some
individuals, while its occurrence in that of others, in the same neigh-
borhood, was not observed. Some, as I have been told, have lost
ten, twelve, or a greater number of patients, in scarcely broken suc-

* An Account, &c. p. 71. t Lond. Med. Gaz. May 2, 1835.

Contagiousness of Puerperal Fever. 9

cession ; like their evil genius, the puerperal fever has seemed to
stalk behind them wherever they went. Some have deemed it pru-
dent to retire for a time from practice. In fine, that this fever may
occur spontaneously, I admit ; that its infectious nature may be
plausibly disputed, I do not deny ; but I add, considerately, that in
my own family, I had rather that those I esteemed the most should
be delivered, unaided, in a stable, by the manger-side, than that they
should receive the best help, in the fairest apartment, but exposed to
the vapors of this pitiless disease. Gossiping friends, wet nurses,
monthly nurses, the practitioner himself, these are the channels by
which, as I suspect, the infection is principally conveyed." *

At a meeting of the Royal Medical and Chirurgical Society, Dr.
King mentioned that some years since a practitioner at Woolwich
lost sixteen patients from puerperal fever in the same year. He was
compelled to give up practice for one or two years, his business be-
ing divided among the neighboring practitioners. No case of puer-
peral fever occurred afterwards, neither had any of the neighboring-
surgeons any cases of this disease.

At the same meeting Mr. Hutchinson mentioned the occurrence
of three consecutive cases of puerperal fever, followed subsequently
by two others, all in the practice of one accoucheur.f

Dr. Lee makes the following statement. '• In the last two weeks
of September, 1327. five fatal cases of uterine inflammation came
under our observation. All the individuals so attacked had been at-
tended in labor by the same midwife, and no example of a febrile or
inflammatory disease of a serious nature occurred during that period
among the other patients of the Westminster General Dispensary,
who had been attended by the other midwives belonging to that in-
stitution."J

The recurrence of long series of cases like those I have cited, re-
ported by those most interested to disbelieve in contagion, scattered
along through an interval of half a century, might have been thought
sufficient to satisfy the minds of all inquirers that here was something
more than a singular coincidence. But if on a more extended ob-
servation, it should be found that the same ominous groups of cases,
clustering about individual practitioners, were observed in a remote
country, at different times, and in widely separated regions, it would

* Lect. on Midwifery, p. 393.
+ Lancet, May 2, 1840.

♦ Lond. Gyc. of Pract. Med., Art. Fever, Puerperal.

2

1 o Contagiousness of Puerperal Fever.

seem incredible that any should be found too prejudiced or indolent
to accept the solemn truth knelled into their ears by the funeral
bells from both sides of the ocean — the plain conclusion that the
physician and the disease entered, hand in hand, into the chamber
of the unsuspecting patient.

That such series of cases have been observed in this country, and
in this neighborhood, I proceed to show.

In Dr. Francis's Notes to Denman's Midwifery, a passage is cited
from Dr. Hosack, in which he refers to certain puerperal cases which
proved fatal to several lying-in women, and in some of which the
disease was supposed to be conveyed by the accoucheurs themselves.*

A writer in the N. Y. Medical and Physical Journal for October,
1829, in speaking of the occurrence of puerperal fever, confined to
one man's practice, remarks, " We have known cases of this kind
occur, though rarely, in New York."

I mention these little hints about the occurrence of such cases,
partly because they are the first I have met with in American med-
ical literature, but more especially because they serve to remind us
that behind the fearful array of published facts, there lies a dark list
of similar events, unwritten in the records of science, but long re-
membered by many a desolated fireside.

Certainly nothing can be more open and explicit than the account
given by Dr. Peirson, of Salem, of the cases seen by him. In the first
nineteen days of January, 1829, he had five consecutive cases of pu-
erperal fever, every patient he attended being attacked, and the three
first cases proving fatal. In March, of the same year, he had two
moderate cases ; in June, another case, and in July, another, which
proved fatal. "Up to this period," he remarks, " I am not informed
that a single case had occurred in the practice of any other physi-
cian. Since that period I have had no fatal case in my practice, al-
though I have had several dangerous cases. I have attended in all
twenty cases of this disease, of which four have been fatal. I am
not aware that there has been any other case in the town of distinct
puerperal peritonitis, although I am willing to admit my information
may be very defective on this point. I have been told of some
" mixed cases," and " morbid affections after delivery." f

In the Quarterly Summary of the Transactions of the College of
Physicians of Philadelphia,^ may be found some most extraordinary

* DenmarTs Midwifery, p. 675, 3d Am. Ed.
+ Remarks on Puerperal Fever, pp. 12 and 13.
t For May, June, and July, 1842.

Contagiousness of Puerperal Fever. 1 1

developments respecting a series of cases occurring in the practice
of a member of that body.

Dr. Condie called the attention of the Society to the prevalence at
the present time, of puerperal fever of a peculiarly insidious and ma-
lignant character. " In the practice of one gentleman extensively
engaged as an obstetrician, nearly every female he has attended in
confinement, during several weeks past, within the above limits,"
(the southern sections and neighboring districts) " had been attack-
ed by the fever."

" An important query presents itself, the Doctor observed, in
reference to the particular form of fever now prevalent. Is it, name-
ly, capable of being propagated by contagion, and is a physician who
has been in attendance upon a case of the disease, warranted in con-
tinuing, without interruption, his practice as an obstetrician? Dr. C,
although not a believer in the contagious character of many of those
affections generally supposed to be propagated in this manner, has
nevertheless become convinced by the facts that have fallen under
his notice, that the puerperal fever now prevailing, is capable of be-
ing communicated by contagion. How otherwise can be explained
the very curious circumstance of the disease in one district being ex-
clusively confined to the practice of a single physician, a Fellow of
this College, extensively engaged in obstetrical practice — while no
instance of the disease has occurred in the patients under the care
of any other accoucheur practising within the same district ; scarcely
a female that has been delivered for weeks past has escaped an
attack ? "

Dr. Rutter, the practitioner referred to, " observed that after the
occurrence of a number of cases of the disease in his practice, he
had left the city and remained absent for a week, but on returning,
no article of clothing he then wore having been used by him before,
one of the very first cases of parturition he attended was followed by
an attack of the fever, and terminated fatally ; he cannot, readily,
therefore, believe in the transmission of the disease from female to
female, in the person or clothes of the physician."

The meeting at which these remarks were made was held on the
third of May, 1842. In a letter dated December 20, 1842, addressed
to Dr. Meigs, and to be found in the Medical Examiner,* he speaks of
" those horrible cases of puerperal fever, some of which you did me
the favor to see with me during the past summer," and talks of his

* For Jan. 21, 1843.

12 Contagiousness of Puerperal Fever.

experience in the disease, " now numbering nearly 70 cases, all of
which have occurred within less than a twelvemonth past."

And Dr. Meigs asserts, on the same page, " Indeed, I believe that
his practice in that department of the profession, was greater than
that of any other gentlemen, which was probably the cause of his
seeing a greater number of the cases." This from a professor of
midwifery, who some time ago assured a gentleman whom he met
in consultation, that the night on which they met was the eighteenth
in succession that he himself had been summoned from his repose,*
seems hardly satisfactory.

I must call the attention of the inquirer most particularly to the
Quarterly Report above referred to, and the letters of Dr. Meigs and
Dr. Rutter, to be found in the Medical Examiner. Whatever im-
pression they may produce upon his mind, I trust they will at least
convince him that there is some reason for looking into this ap-
parently uninviting subject.

At the meeting of the College of Physicians just mentioned,
Dr. Warrington stated that a few days after assisting at an autopsy
of puerperal peritonitis, in which he laded out the contents of the
abdominal cavity with his hands, he was called upon to deliver three
women in rapid succession. All of these women were attacked with
different forms of what is commonly called puerperal fever. Soon
after these he saw two other patients, both on the same day, with
the same disease. Of these five patients two died.

At the same meeting, Dr. West mentioned a fact related to him by
Dr. Samuel Jackson, of Northumberland. Seven females, delivered
by Dr. Jackson in rapid succession, while practising in Northumber-
land county, were all attacked with puerperal fever, and five of them
died. " Women," he said, " who had expected me to attend upon
them, now becoming alarmed, removed out of my reach, and others
sent for a physician residing several miles distant. These women,
as well as those attended by midwives, all did well; nor did we hear
of any deaths in childbed within a radius of fifty miles, excepting
two, and these I afterwards ascertained to have been caused by other
diseases." He underwent, as he thought, a thorough purification,
and still his next patient was attacked with the disease and died.
He was led to suspect that the contagion might have been carried in
the gloves which he had worn in attendance upon the previous cases.
Two months or more after this he had two other cases. He could

* Med. Examiner for Dec. 10. 1842.

Contagiousness of Puerperal Fever. 13

find nothing to account for these, unless it were the instruments for
giving enemata which had been used in two of the former cases, and
were employed by these patients. When the first case occurred, he
was attending and dressing a limb extensively mortified from ery-
sipelas, and went immediately to the accouchement with his clothes
and gloves most thoroughly imbued with its effluvia. And here I
may mention, that this very Dr. Samuel Jackson, of Northumber-
land, is one of Dr. Dewees's authorities against contagion.

The three following statements are now for the first time given to
the public. All of the cases referred to occurred within this State,
and two of the three series in Boston and its immediate vicinity.

I. The first is a series of cases which took place during the last
spring in a town at some distance from this neighborhood. A phy-
sician of that town, Dr. C, had the following consecutive cases.

No. 1, delivered March 20, died March 24.

2, " April 9, " April 14.

3, " 10, " " 14.

4, " 11, " " 18.

5, " 27, " May 3.

6, " 28, Had some symptoms, recovered.

7, " May 8, Had some symptoms, also recovered.
These were the only cases attended by this physician during the

period referred to. " They were all attended by him until their ter-
mination, with the exception of the patient No. 6, who fell into the
hands of another physician on the 2d of May. (Dr. C. left town for a
few days at this time.) Dr. C. attended cases immediately before
and after the above-named periods, none of which, however, presented
any peculiar symptoms of the disease."

About the first of July, he attended another patient in a neighbor-
ing village, who died two or three days after delivery.

The first patient, it is stated, was delivered on the 20th of March.
" On the 19th. Dr. C. made the autopsy of a man who died suddenly,
sick only 48 hours ; had oedema of the thigh, and gangrene extend-
ing from a little above the ankle into the cavity of the abdomen."
Dr. C. wounded himself, very slightly, in the right hand during the
autopsy. The hand was quite painful the night following, during
his attendance on the patient No. 1. He did not see this patient
after the 20th, being confined to the house, and very sick from the
wound just mentioned, from this time until the third of April.

1 } Contagiousness of Puerperal Fever.

Several cases of erysipelas occurred in the house where the au-
topsy mentioned above took place, soon after the examination.
There were also many cases of erysipelas in town at the time of the
fatal puerperal cases which have been mentioned.

The nurse who laid out the body of the patient No. 3, was taken
on the evening of the same day with sore throat and erysipelas, and
died in ten days from the first attack.

The nurse who laid out the body of the patient No. 4, was taken
on the day following with symptoms like those of this patient, and
died in a week, without any external marks of erysipelas.

'•No other cases of similar character with those of Dr. C. occurred
in the practice of any of the physicians in the town or vicinity at the
time. Deaths following confinement have occurred in the practice
of other physicians during the past year, but they were not cases of
puerperal fever. No post-mortem examinations were held in any of
these puerperal cases."

Some additional statements in this letter are deserving of insertion.

" A physician attended a woman in the immediate neighborhood
of the cases numbered 2, 3 and 4. This patient was confined the
morning of March 1st, and died on the night of March 7th. It is
doubtfal whether this should be considered a case of puerperal fever.
She had suffered from canker, indigestion and diarrhoea for a year
previous to her delivery. Her complaints were much aggravated for
two or three months previous to delivery ; she had become greatly
emaciated, and weakened to such an extent, that it had not been ex-
pected that she would long survive her confinement, if indeed she
reached that period. Her labor was easy enough ; she flowed a
good deal, seemed exceedingly prostrated, had ringing in the ears,
and other symptoms of exhaustion ; the pulse was quick and small.
On the second and third day there was some tenderness and tume-
faction of the abdomen, which increased somewhat on the fourth and
fifth. He had cases in midwifery before and after this, which pre-
sented nothing peculiar."

It is also mentioned in the same letter, that another physician
had a case which happened last summer and another last fall, both of
which recovered.

Another gentleman reports a case last December, a second case
five weeks and another three weeks since. All these recovered. A
case also occurred very recently in the practice of a physician in the
village where the eighth patient of Dr. C. resides, which proved fatal.

Contagiousness of Puerperal Fever. 1 5

" This patient had some patches of erysipelas on the legs and arms.
The same physician has delivered three cases since, which have all
done well. There have been no other cases in this town or its
vicinity recently. There have been some few cases of erysipelas."
It deserves notice that the partner of Dr. C, who attended the autopsy
of the man above-mentioned and took an active part in it ; who also
suffered very slightly from a prick under the thumb nail received
durinjr the examination, had twelve cases of midwifery between
March 26th and April 12th, all of which did well, and presented no
peculiar symptoms. It should also be stated, that during these 17
days he was in attendance on all the cases of erysipelas in the house
where the autopsy had been performed.

I owe these facts to the prompt kindness of a gentleman whose
intelligence and character are sufficient guaranty for their accuracy.

The two following letters were addressed to my friend Dr. Storer,
by the gentlemen in whose practice the cases of puerperal fever oc-
curred. His name renders it unnecessary to refer more particularly
to these gentlemen, who on their part have manifested the most per-
fect freedom and courtesy in affording these accounts of their pain-
ful experience.

n l Jan. 28, 1843.

jj *##* <t The time to which you allude was in 1830. The first
case was in February, during a very cold time. She was confined
the 4th and died the 12th. Between the 10th and 28th of this
month, I attended 'six women in labor, all of whom did well except
the last, as also two who were confined March 1st and 5th. Mrs.
E., confined Feb. 28th, sickened, and died March 8th. The next
day, 9th, I inspected the body, and the night after attended a lady,
Mrs. B.. who sickened, and died 16th. The 10th, 1 attended another, »
Mrs. G., who sickened, but recovered. March 16th, I went from
Mrs. G.'s room to attend a Mrs. H., who sickened, and died 21st.
The 17th, I inspected Mrs. B. On 19th, I went directly from Mrs.
H.'s room to attend another lady, Mrs. G., who also sickened, and
died 22d. While Mrs. B. was sick, on 15th, I went directly from
her room a few rods, and attended another woman, who was not
sick. Up to 20th of this month I wore the same clothes. I now re-
fused to attend any labor, and did not till April 21st, when having
thoroughly cleansed myself, I resumed my practice, and had no
more puerperal fever.

1 6 Contagiousness of Puerperal Fever.

" The cases were not confined to a narrow space. The two nearest
were half a mile from each other, and half that distance from my re-
sidence. The others were from two to three miles apart, and nearly
that distance from my residence. There were no other cases in
their immediate vicinity which came to my knowledge. The general
health of all the women, was pretty good, and all the labors as good
as common except the first. This woman, in consequence of my
not arriving in season, and the child being half born some time be-
fore I arrived, was very much exposed to the cold at the time of
confinement, and afterwards, being confined in a very open cold
room. Of the six cases you perceive only one recovered.

" In the winter of 181-7 two of my patients had puerperal fever,
one very badly, the other not so badly. Both recovered. One other
had swelled leg, or phlegmasia dolens, and one or two others did
not recover as well as usual.

" In the summer of 1335 another disastrous period occurred in my
practice. July 1st, I attended a lady in labor, who was afterwards
quite ill and feverish ; but at the time I did not consider her case a
decided puerperal fever. On 8th, I attended one who did well. On
12th, one who was seriously sick. This was also an equivocal case,
apparently arising from constipation and irritation of the rectum.
These women were ten miles apart and five from my residence.
On 15th and 20th, two who did well. On 25th, I attended another.
This was a severe labor, and followed by unequivocal puerperal
fever, or peritonitis. She recovered. August 2d and 3d, in about
twenty-four hours I attended four persons. Two of them did very
well ; one was attacked with some of the common symptoms, which
however subsided in a day or two, and the other had decided puer-
peral fever, but recovered. This woman resided five miles from me.
Up to this time I wore the same coat. All my other clothes had
frequently been changed. On 6th, I attended two women, one of
whom was not sick at all ; but the other, Mrs. L., was afterwards
taken ill. On 10th, I attended a lady, who did very well. I had
previously changed all my clothes, and had no garment on which
had been in a puerperal room. On 12th, I was called to Mrs. S., in
labor. While she was ill, I left her to visit Mrs. L., one of the ladies
who was confined on 6th. Mrs. L. had been more unwell than
usual, but I had not considered her case any thing more than com-
mon till this visit. I had on a surtout at this visit, which on my re-
turn to Mrs. S., I left in another room. Mrs. S. was delivered on

Contagiousness of Puerperal Fever. 17

13th with forceps. These women both died of decided puerperal
fever.

" While I attended these women in their fevers, I changed my
clothes, and washed my hands in a solution of chloride of lime after
each visit. I attended seven women in labor during this period, all
of whom recovered without sickness.

"In my practice I have had several single cases of puerperal fever,
some of whom have died and some have recovered. Until the year
1830, I had no suspicion that the disease could be communicated
from one patient to another by a nurse or midwife ; but I now think
the foregoing facts strongly favor that idea. I was so much con-
vinced of this fact, that I adopted the plan before related.

" I believe my own health was as good as usual at each of the
above periods. I have no recollection to the contrary.

" I believe I have answered all your questions. I have been more
particular on some points perhaps than necessary ; but I thought
you could form your own opinion better than to take mine. In
1830, I wrote to Dr. Channing a more particular statement of my
cases. If I have not answered your questions sufficiently, perhaps
Dr. C. may have my letter to him, and you can find your answer
there." *

Boston, Feb. 3, 1843.

III. " My Dear Sir, — I received a note from you last evening, re-
questing me to answer certain questions therein proposed, touching
the cases of puerperal fever which came under my observation the
past summer. It gives me pleasure to comply with your request, so
far as it is in my power so to do, but owing to the hurry in preparing
for a journey, the notes of the cases I had then taken, were lost or
mislaid. The principal/«c£s, however, are too vivid upon my recol-
lection to be soon forgotten. I think, therefore, that I shall be able
to give you all the information you may require.

"All the cases that occurred in my practice, took place between the
7th of May and the 17th of June, 1842.

" They were not confined to any particular part of the city. The
two first cases were patients residing at the south-end, the next was
at the extreme north-end. one living in Sea street and the other in
Roxbury. The following is the order in which they occurred.

* In a letter to myself, this gentleman also stated. " I do not recollect that there was any
erysipelas or any other disease particularly prevalent at the time."

3

18 Contagiousness of Puerperal Fever.

" Case 1 . Mrs. was confined on the 7th of May, at 5 o'clock,

P. M., after a natural labor of six hours. At 12 o'clock at night, on
the 9th (thirty-one hours after confinement), she was taken with se-
vere chill, previous to which she was as comfortable as women
usually are under the circumstances. She died on the 10th.

" Case 2. Mrs. was confined on the 10th of June (four

weeks after Mrs. C), at 11, A. M., after a natural, but somewhat
severe labor of 5 hours. At 7 o'clock, on the morning of the 11th,
she had a chill. Died on the 12th.

" Case 3. Mrs. , confined on the 14th of June, was comfort-
able until the 3 8th, when symptoms of puerperal fever were mani-
fest. She died on the 20th.

" Case 4. Mrs. , confined June 17th, at 5 o'clock, A. M.,

was doing well until the morning of the 19th. She died on the
evening of. the 21st.

•'Case 5. Mrs. was confined with her fifth child on the 17th

of June, at 6 o'clock in the evening. This patient had been at-
tacked with puerperal fever, at three of her previous confinements,
but the disease yielded to depletion and other remedies without dif-
ficulty. This time, I regret to say, I was not so fortunate. She
was not attacked, as were the other patients, with a chill, but com-
plained of extreme pain in abdomen, and tenderness on pressure,
almost from the moment of her confinement. In this, as in the other
cases, the disease resisted all remedies, and she died in great distress
on the 22d of the same month. Owing to the extreme heat of the
season, and my own indisposition, none of the subjects were exam-
ined after death. Dr. Channing, who was in attendance with me on
the three last cases, proposed to have a post-mortem examination of
the subject of case No. 5, but from some cause which I do not now
recollect, it was not obtained.

" You wish to know whether I wore the same clothes when at-
tending the different cases. I cannot positively say, but I should
think I did not, as the weather became warmer after the first two
cases ; I therefore think it probable that I made a change of at least a
part of my dress. I have had no other case of puerperal fever in my
own practice for three years, save those above related, and 1 do not
remember to have lost a patient before with this disease. While
absent, last July, I visited two patients sick with puerperal fever,
with a friend of mine in the country. Both of them recovered.

" The cases that I have recorded, were not confined to any par-

Contagiousness of Puerperal Fever. 1 9

ticular constitution or temperament, but it seized upon the strong
and the weak, the old and the young — one being over 40 years, and
youngest under 18 years of age.***** If the disease is of an erysipe-
latous nature, as many suppose, contagionists may perhaps find some
ground for their belief in the fact that for two weeks previous to my
first case of puerperal fever, I had been attending a severe case of
erysipelas, and the infection may have been conveyed through me
to the patient ; but on the other hand, why is not this the case with
other physicians, or with the same physician at all times, for since
my return from the country I have had a more inveterate case of
erysipelas than ever before, and no difficulty whatever has attended
any of my midwifery cases."

I am assured, on unquestionable authority, that "About three
years since, a gentleman in extensive midwifery business, in a neigh-
boring State, lost in the course of a few weeks eight patients in
child-bed, seven of them being undoubted cases of puerperal fever.
No other physician of the town lost a single patient of this disease
during the same period." And from what 1 have heard in conver-
sation with some of our most experienced practitioners, I am inclined
to think many cases of the kind might be brought to light by ex-
tensive inquiry.

This long catalogue of melancholy histories assumes a still darker
aspect when we remember how kindly nature deals with the par-
turient female, when she is not immersed in the virulent atmosphere of
an impure lying-in hospital, or poisoned in her chamber by the un-
suspected breath of contagion. From all causes together, not more
than four deaths in a thousand births and miscarriages, happened in
England and Wales during the period embraced by the first Report
of the Registrar-General.* In the second Report the mortality was
shown to be about five in one thousand. f In the Dublin Lying-in
Hospital, during the seven years of Dr. Collins's mastership, there
was one case of puerperal fever to 178 deliveries, or less than six to
the thousand, and one death from this disease in 278 cases, or be-
tween three and four to the thousand.."): Yet during this period the
disease was endemic in the hospital, and might have gone on to rival
the horrors of the pestilence of the Maternite, had not the poison
been destroyed by a thorough purification.

* 1st Report, p. 105. t 2d Report, p. 73. t Collins's Midwifery, p. 228, etc.

\

-20 Contagiousness of Puerperal Fever.

In private practice, leaving out of view the cases that are to be as-
cribed to the self-acting system of propagation, it would seem that the
disease must be far from common. Mr. White, of Manchester, says,
<: Out of the whole number of lying-in patients whom I have delivered
(and 1 may safely call it a great one), I have never lost one, nor to the
best of my recollection has one been greatly endangered, by the puer-
peral, miliary, low nervous, putrid malignant, or milk fever." * Dr.
Joseph Clarke informed Dr. Collins, that in the course of forty-five
years' most extensive practice, he lost but four patients from this dis-
eise.f One of the most eminent practitioners of Glasgow, who has been
engaged in very extensive practice for upwards of a quarter of a
century, testifies that he never saw more than twelve cases of real
puerperal fever.J

I have myself been told by two gentlemen practising in this city,
and having for many years a large midwifery business, that they had
neither of them lost a patient from this disease, and by one of them
that he had only seen it in consultation with other physicians. In
five hundred cases of midwifery of which Dr. Storer has given an ab-
stract in the first number of this Journal, there was only one instance
of fatal puerperal peritonitis.

In the view of these facts, it does appear a singular coincidence,
that one man or woman should have ten, twenty, thirty, or seventy
cases of this rare disease, following their footsteps with the keenness
of a beagle, through the streets and lanes of a crowded city, while the
scores that cross the same paths on the same errands know it only
by name. It is a series of similar coincidences that has led us to
consider the dagger, the musket, and certain innocent looking white
powders, as having some little claim to be regarded as danger-
ous. It is the practical inattention to similar coincidences that has
given rise to the unpleasant but often necessary documents called
indictments, that has sharpened a form of the cephalotome some-
times employed in the case of adults, and adjusted that modification
of the fillet which delivers the world of those who happen to be too
much in the way while such striking coincidences are taking place.

I shall now mention a few instances in which the disease appears
to have been conveyed by the process of direct inoculation.

Dr. Campbell, of Edinburgh, states that in October, 1821, he as-
sisted at the post-mortem examination of a patient who died with

* Op. cit. p. 116. t Collins's Treatise on Midwifery, p. 223. t Lancet, May 4, 1833.

Contagiousness of Puerperal Fever. 21

puerperal fever. He carried the pelvic viscera in his pocket to the
class room. The same evening he attended a woman in labor with-
out previously changing his clothes; this patient died. The next
morning he delivered a woman with the forceps ; she died also, and
of many others who were seized with the disease within a few weeks,
three shared the same fate in succession.

In June, 1823, he assisted some of his pupils at the autopsy of a
case of puerperal fever. He was unable to wash his hands with
proper care, for want of the necessary accommodations. On getting
home he found two patients required his assistance. He went with-
out further ablution, or changing his clothes ; both these patients
died with puerperal fever.* This same Dr. Campbell is one of Dr.
Churchill's authorities against contagion.

Mr. Roberton says that in one instance within his knowledge, a
practitioner passed the catheter for a patient with puerperal fever
late in the evening ; the same night he attended a lady who had the
symptoms of the disease on the second day. In another instance a
surgeon was called while in the act of inspecting the body of a wo-
man who had died of this fever, to attend a labor ; within forty-
eight hours this patient was seized with the fever.f

On the 16th of March, 1831, a medical practitioner examined the
body of a woman who had died a few days after delivery, from puer-
peral peritonitis. On the evening of the 17th he delivered a patient
who was seized with puerperal fever on the 19th, and died on the
24th. Between this period and the 6th of April, the same practi-
tioner attended two other patients, both of whom were attacked with
the same disease and died. J

In the autumn of 1829, a physician was present at the examina-
tion of a case of puerperal fever, dissected out the organs, and assist-
ed in sewing up the body. He had scarcely reached home when he
was summoned to attend a young lady in labor. In sixteen hours
she was attacked with the symptoms of puerperal fever, and narrowly
escaped with her life.§

In December, 1830, a midwife who had attended two fatal cases
of puerperal fever at the British Lying-in Hospital, examined a patient
who had just been admitted, to ascertain if labor had commenced.
This patient remained two days in the expectation that labor would
come on, when she returned home and was then suddenly taken in

* London Med. Gaz. Dec. 10th, 1831. t Ibid, for Jan. 1832. * London Cyc. of Praet.
Med., Art. Fever, Puerperal. § Ibid.

82 Contagiousness of Puerperal Fever.

labor, and delivered before she could set out for the hospital. She
went on favorably for two days, and was then taken with puerperal
fever and died in thirty-six hours.*

" A young practitioner, contrary to advice, examined the body of
a patient who had died from puerperal fever; there was no epide-
mic at the time ; the case appeared to be purely sporadic. He de-
livered three other women shortly afterwards ; they all died with pu-
erperal fever, the symptoms of which broke out very soon after labor.
The patients of his colleague did well, except one, where he assisted to
remove some coagula from the uterus ; she was attacked in the same
manner as those whom he had attended, and died also." The writer
in the British and Foreign Medical Review, from whom I quote this
statement — and who is no other than Dr. Ptigby — adds, " we trust
that this fact alone will forever silence such doubts, and stamp the
well-merited epithet of ' criminal,' as above quoted, upon such
attempts, "f

From the cases given by Mr. Ingleby, I select the following. Two
gentlemen, after having been engaged in conducting the post-mortem
examination of a case of puerperal fever, went in the same dress, each
respectively, to a case of midwifery. " The one patient was seized
with the rigor about thirty hours afterwards. The other patient was
seized with a rigor the third morning after delivery. One recovered,
one died."% One of these same gentlemen attended another woman
in the same clothes two days after the autopsy referred to. "The
rigor did not take place until the evening of the fifth day from the
first visit. Result fatal." These cases belonged to a series of seven,
the first of which was thought to have originated in a case of ery-
sipelas. " Several cases of a mild character followed the foreo-oinsr
seven, and their nature being now most unequivocal, my friend de-
clined visiting all midwifery cases for a time ; and there was no re-
currence of the disease." These cases occurred in 1833. Five of
them proved fatal. Mr. Ingleby gives another series of seven cases
which occurred to a practitioner in 1836, the first of which was also
attributed to his haying opened several erysipelatous abscesses a short
time previously.

I need not refer to the case lately read before this Society, in which
a physician went, soon after performing an autopsy of a case of pu-
erperal fever, to a woman in labor, who was seized with the same

* London Cyc. of Pract. Med., Art. Fever, Puerperal, t Brit, and For. Medical Review,
/or Jan. 1842, p. 112. t Edin. Med. and Surg. Journal, April, 1838.

Contagiousness of Puerperal Fever. 23

disease and perished. The forfeit of that error has been already
paid.

At the meeting of the Medical and Chirurgical Society before re-
ferred to, Dr. Merriman related an instance occurring in his own
practice, which excites a reasonable suspicion that two lives were
sacrificed to a still less dangerous experiment. He was at the ex-
amination of a case of puerperal fever at 2 o'clock in the afternoon.
He took care not to touch the body. At 9 o'clock the same eve-
ning he attended a woman in labor ; she was so nearly delivered
that he had scarcely any thing to do. The next morning she had
severe rigors, and in 48 hours was a corpse. Her infant had erysi-
pelas and died in two days.*

In connection with the facts which have been stated, it seems
proper to allude to the dangerous and often fatal effects which have
followed from wounds received in the post-mortem examination of
patients who have died of puerperal fever. The fact that such wounds
are attended with peculiar risk has been long noticed. I find that
Chaussier was in the habit of cautioning his students against the
danger to which they were exposed in these dissections. f The head
pharmacien of the Hotel Dieu, in his analysis of the fluid effused in
puerperal peritonitis, says that practitioners are convinced of its de-
leterious qualities, and that it is very dangerous to apply it to the
denuded skin. J Sir Benjamin Brodie speaks of it as being well
known that the inoculation of lymph or pus from the peritoneum of
a puerperal patient is often attended with dangerous and even fatal
symptoms. Three cases in confirmation of this statement, two of
them fatal, have been reported to this Society within a few months.

Of about fifty cases of injuries of. this kind, of various degrees of se-
verity, which I have collected from different sources, at least twelve
were instances of infection from puerperal peritonitis. Some of
the others are so stated as to render it probable that they may have
been of the same nature. Five other cases were of peritoneal inflam-
mation ; three in males. Three were of what was called enteritis,
in one instance complicated with erysipelas ; but it is well known
that this term has been often used to signify inflammation of the perito-
neum covering the intestines. On the other hand, no case of ty-
phus or typhoid fever is mentioned as giving rise to dangerous con-
sequences, with the exception of the single instance of an underta-

* Lancet, May 2d, 1640. t Stein, l'Art de Accoucher, 1794. Diet, des Sciences Medicales,
Art. Puerperal, t Journal de Pharmacie, Jan. IS36.

21 Contagiousness of Puerperal Fever.

ker mentioned by Mr. Travers, who seems to have been poisoned
by a fluid which exuded from the body. The other accidents were
produced by dissection, or some other mode of contact with bodies
of patients who had died of various affections. They also differed
much in severity, the cases of puerperal origin being among the
most formidable and fatal. Now a moment's reflection will show that
the number of cases of serious consequences ensuing from the dis-
section of the bodies of those who have perished of puerperal fever,
is so vastly disproportioned to the relatively small number of autop-
sies made in this complaint as compared with typhus, or pneumonia,
(from which last disease not one case of poisoning happened), and
still more from all diseases put together, that the conclusion is irresis-
tible that a most fearful morbid poison is often generated in the
course of this disease. Whether or not it is sui generis, confined
to this disease, or produced in some others, as for instance erysipe-
las, I need not stop to inquire.

In connection with this may be taken the following statement of Dr.
Pugby. " That the discharges from a patient under puerperal fever are
in the highest degree contagious, we have abundant evidence in the
history of lying-in hospitals. The puerperal abscesses are also con-
tagious, and may be communicated to healthy lying-in women by
washing with the same sponge ; this fact has been repeatedly proved
in the Vienna Hospital ; but they are equally communicable to wo-
men not pregnant ; on more than one occasion the women engaged
in washing the soiled bed-linen of the General Lying-in Hospital
have been attacked with abscess in the fingers or hands, attended
with rapidly spreading inflammation of the cellular tissue."*

Now add to all this the undisputed fact that within the walls of ly-
ing-in hospitals there is often generated a miasm, palpable as the chlo-
rine used to destroy it, tenacious so as in some cases almost to defy
extirpation, deadly in some institutions as the plague; which has
killed women in a private hospital of London so fast that they were
buried two in one coffin to conceal its- horrors ; which enabled To-
nelle to record two hundred and twenty-two autopsies at the Mater-
nite of Paris ; which has led Dr. Lee to express his deliberate con-
viction that the loss of life occasioned by these institutions completely
defeats the object of their founders ; and out of this train of cumula-
tive evidence, the multiplied groups of cases clustering about indi-

* System of Midwifery, p. 292.

Contagiousness of Puerperal Fever. 25

viduals, the deadly results of autopsies, the inoculation by fluids from
the living patient, the murderous poison of hospitals, does there not
result a conclusion that laughs all sophistry to scorn, and renders all
argument an insult :

I have had occasion to mention some instances in which there was
an apparent relation between puerperal fever and erysipelas. The
length to which this paper has extended does not allow me to enter
into the consideration of this most important subject. I will only
say that the evidence appears to me altogether satisfactory that some
most fatal series of puerperal fever have been produced by an infec-
tion originating in the matter or effluvia of erysipelas. In evidence
of some connection between the two diseases, I need not go back to
the older authors, as Pouteau or Gordon, but will content myself with
giving the following references, with their dates ; from which it will
be seen that the testimony has been constantly coming before the
profession for the last few years.

London Cyclopedia of Practical Medicine — article Puerperal Fe-
ver. 18:33.

Mr. Ceeley's Account of the Puerperal Fever at Aylesbury. Lan-
cet, 1835.

Dr. Ramsbotham's Lecture. London Medical Gazette, 1835.

Mr. Yates Ackerley's Letter in the same Journal, 1838.

Mr. Ingleby on Epidemic Puerperal Fever. Edinburgh Medical
and Surgical Journal, 1838.

Mr. Paley's Letter. London Medical Gazette, 1839.

Remarks at the Medical and Chirurgical Society. Lancet, 1840.

Dr. Rigby's System of Midwifery. 1841.

Nunneley on Erysipelas — a work which contains a large number of
references on the subject. 1841.

British and Foreign Quarterly Review, 1842.

Dr. S. Jackson, of Northumberland, as already quoted from the
Summary of the College of Physicians, 1842.

And lastly, a startling series of cases by Mr. Storrs, of Doncaster,
to be found in the American Journal of the Medical Sciences for
January, 1843.

The relation of puerperal fever with other continued fevers, would

seem to be remote and rarely obvious. Hey refers to two cases of

synochus occurring in the Royal Infirmary of Edinburgh, in women

who had attended upon puerperal patients. Dr. Collins refers to

4

26 Contagiousness of Puerperal Fever.

several instances in which puerperal fever has appeared to originate
from a continued proximity to patients suffering with typhus.*

Such occurrences as those just mentioned, though most impor-
tant to be remembered and guarded against, hardly attract our no-
tice in the midst of the gloomy facts by which they are surrounded.
Of these facts, at the risk of fatiguing repetitions, I have sum-
moned a sufficient number, as I believe, to convince the most incre-
dulous, that every attempt to disguise the truth which underlies
them all, is useless.

It is true that some of the historians of the disease, especially
Hulme, Hull and Leake, in England ; Tonelle, Duges and Baude-
locque, in France, profess not to have found puerperal fever conta-
gious. At the most they give us mere negative facts, worthless
against an extent of evidence which now overlaps the widest range
of doubt, and doubles upon itself in the redundancy of superfluous
demonstration. Examined in detail, this and much of the show of testi-
mony brought up to stare the daylight of conviction out of counte-
nance, proves to be in a great measure unmeaning or inapplicable, as
might be easily shown were it necessary. Nor do I feel the necessity
of enforcing the conclusion which arises spontaneously from the facts
which have been enumerated, by formally citing the opinions of those
grave authorities who have for the last half century been sounding
the unwelcome truth it has cost so many lives to establish.

" It is to the British practitioner," says Dr. Rigby, " that we are
indebted for strongly insisting upon this important and dangerous
character of puerperal fever. "f

The names of Gordon, John Clarke, Denman, Burns, Young,J
Hamilton,^ Haighton,|| Good,*U Waller,** Blundell, Gooch, Rams-
botham, Douglas,tf Lee, Ingleby, Locock,JJ Abercrombie,^ Ali-
son, mi Traversal! Rigby, and Watson,*** many of whose writings I
have already referred to, may have some influence with those who pre-
fer the weight of authorities to the simple deductions of their own rea-
son from the facts laid before them. A few continental writers have
adopted similar conclusions. fff It gives me pleasure to remember that

* Treatise on Midwifery, p. 223. t British and Foreign Med. Review for Jan. 1842.
t Encyc. Britannica, xiii, 467, Art. Medicine. § Outlines of Midwifeiy, p. 109. || Oral Lec-
tures, &c. IT Study of Medicine, ii. 19.",. ** Medical and Physical Journal, July, 1830.
tt Dublin Hosp. Reports for 1822. $+ Library of Pract. Medicine, i. 373. §§ Researches
on Diseases of the Stomach, &c. p. 181. |||| Lib. of Pract. Medicine, Vol. i. p. 96. 1W Fur-
ther Researches on Constitutional Irritation, p. 128. *** Lond. Med. Gaz. Feb. 1S42. +t+ See
British and Foreign Medical Review, Vol. iii. p. 525, and Vol. iv. p. 517. Also Ed. Med.
and Surg. Journal for July, 1824, and American Journal of Med. Sciences for Jan. 1841.

Contagiousness of Puerperal Fever. 27

while the doctrine has been unceremoniously discredited in one of the
leading Journals,* and made very light of by teachers in two of the
principal Medical Schools of this country, Dr. Channing has for many
years inculcated and enforced by examples the danger to be appre-
hended and the precautions to be taken in the disease under con-
sideration.

1 have no wish to express any harsh feeling with regard to the
painful subject that has come before us. If there are any so far ex-
cited by the story of these dreadful events, that they ask for some
word of indignant remonstrance, to show that science does not turn
the hearts of its followers into ice or stone, let me remind them that
such words have been uttered by those who speak with an authority
I could not claim. f It is as a lesson rather than as a reproach that I
call up the memory of these irreparable errors and wrongs. No
tongue can tell the heart-breaking calamity they have caused ; they
have closed the eyes just opened upon a new world of love and
happiness ; they have bowed the strength of manhood into the dust;
they have cast the helplessness of infancy into the stranger's arms, or
bequeathed it with less cruelty the death of its dying parent. There
is no tone deep enough for regret, and no voice loud enough for warn-
ing. The woman about to become a mother, or with her new-born
infant upon her bosom, should be the object of trembling care and
sympathy wherever she bears her tender burden, or stretches her
aching limbs. The very outcast of the streets has pity upon her
sister in degradation when the seal of promised maternity is impressed
upon her. The remorseless vengeance of the law, brought down
upon its victim by a machinery as sure as destiny, is arrested in its
fall at a word which reveals her transient claim for mercy. The
solemn prayer of the liturgy singles out her sorrows from the multi-
plied trials of life, to plead for her in the hour of peril. God forbid
that any member of the profession to which she trusts her life,
doubly precious at that eventful period, should hazard it negligently,
unadvisedly, or selfishly !

There may be some among those whom I address, who are dis-
posed to ask the question, What course are we to follow in relation
to this matter? The facts are before them, and the answer must be
left to their own judgment and conscience. If any should care to
know my own conclusions, they are the following ; and in taking
the liberty to state them very freely and broadly, I would ask the

* Phil. Med. Journ. Vol. xii. p. 364. t Dr, Blundell and Dr. Rigby in the works already cited.

28 Contagiousness of Puerperal Fever.

inquirer to examine them as freely in the light of the evidence which
has been laid before him.

1. A physician holding himself in readiness to attend cases of mid-
wifery, should never take any active part in the post-mortem exami-
nation of cases of puerperal fever.

2. If a physician is present at such autopsies, he should use
thorough ablution, change every article of dress, and allow twenty-
four hours or more to elapse before attending to any case of mid-
wifery. It may be well to extend the same caution to cases of sim-
ple peritonitis.

3. Similar precautions should be taken after- the autopsy or sur-
gical treatment of cases of erysipelas, if the physician is obliged to
unite such offices with his obstetrical duties, which is in the highest
degree inexpedient.

4. On the occurrence of a single case of puerperal fever in his
practice, the physician is bound to consider the next female he at-
tends in labor, unless some weeks, at least, have elapsed, as in dan-
ger of being infected by him, and it is his duty to take every pre-
caution to diminish her risk of disease and death.

5. If within a short period two cases of puerperal fever happen close
to each other, in the practice of the same physician, the disease
not existing or prevailing in the neighborhood, he would do wisely
to relinquish his obstetrical practice for at least one month, and en-
deavor to free himself by every available means from any noxious
influence he may carry about with him.

6. The occurrence of three or more closely connected cases, in
the practice of one individual, no others existing in the neighborhood,
and no other sufficient cause being alleged for the coincidence, is
prima facie evidence that he is the vehicle of contagion.

7. It is the duty of the physician to take every precaution that the
disease shall not be introduced by nurses or other assistants, by
making proper inquiries concerning them, and giving timely warning
of every suspected source of danger. ♦

8. Whatever indulgence may be granted to those who have here-
tofore been the ignorant causes of so much misery, the time has
come when the existence of a private pestilence in the sphere of a
single physician should be looked upon not as a misfortune but a
crime ; and in the knowledge of such occurrences, the duties of
the practitioner to his profession, should give way to his paramount
obligations to society.